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On-line version ISSN 1806-907X
Rev. Bras. Anestesiol. vol.57 no.2 Campinas Mar./Apr. 2007
Psoas muscle abscess after epidural analgesia. Case report*
Absceso del músculo psoas en paciente sometida a analgesia por vía peridural. Relato del caso
Durval Campos Kraychete, TSAI; Anita Perpétua Carvalho RochaII; Pedro Augusto Costa Rebouças de CastroIII
em Medicina e Saúde pela UFBA; Professor Adjunto de Anestesiologia na
UFBA; Coordenador do Ambulatório de Dor da UFBA
IIMestre em Anestesiologia pela UNESP; Especialista em Dor; Anestesiologista do Hospital da Sagrada Família, BA
IIIME3 do CET/SBA do Hospital Universitário Professor Edgard Santos, UFBA
OBJECTIVES: Psoas muscle abscess is a rare complication of epidural analgesia.
The adequate approach to this complication is fundamental for a good resolution.
The objective of this report was to discuss the diagnosis and treatment of psoas
CASE REPORT: A female patient, 65 years old, with neuropathic pain in the lower limbs, difficult to control with systemic drugs. The patient was treated with epidural opioid and local anesthetic as an alternate treatment. Twenty days after the continuous epidural administration, the patient complained of lumbar pain, headache, and fever. A CT scan of the pelvis showed an abscess of the psoas muscle, thus, closed drainage and antibiotics were indicated.
CONCLUSIONS: An adequate, continuous supervision of the patient is necessary when an epidural catheter is placed, and it should continue after its removal.
Key Words: COMPLICATIONS: psoas muscle abscess; PAIN, Chronic.
JUSTIFICATIVA Y OBJETIVOS:
El absceso del músculo psoas es una complicación rara de la analgesia
peridural. El manoseo adecuado de esa situación intercurrente es fundamental
para una buena resolución del cuadro clínico. El objetivo de este
relato fue discutir el diagnóstico y el tratamiento del absceso del músculo
RELATO DEL CASO: Paciente del sexo femenino, 65 años, con dolor neuropático en los miembros inferiores de difícil control con medicamentos por vía sistémica. Se optó por la administración de opioide y anestésico local por vía peridural como alternativa analgésica. Veinte días después del uso continuo de la vía peridural, la paciente empezó a presentar dolor en la región lumbar, cefalea y fiebre. La tomografía computadorizada de la pelvis reveló absceso del músculo psoas, siendo indicado el drenado cerrado y antibioticoterapia.
CONCLUSIONES: La supervisión minuciosa del paciente es necesaria y debe ser continua cuando un catéter peridural se pone, y esa vigilancia debe mantenerse después de su retirada.
The origin of the psoas muscle is retroperitoneal, at the anterior surface of the transverse process, on the lateral edge of the vertebral bodies from T12 to L5. It inserts in the lesser trochanter of the femur, a short distance below the medial border of its axis. In 70% of the cases, it is a single structure, the greater psoas. However, 30% of the people also have a minor psoas muscle, anterior to the greater psoas and following the same path. Along with the upper iliac muscle, the psoas is responsible for the flexion of the thigh; inferiorly, all by itself, it makes the lateral rotation of the vertebral column, and with the iliac muscles it makes the flexion of the trunk. Therefore, its functions include the flexion of the thigh over the hip, and minimal lateral rotation and abduction of the thigh.
The psoas muscle has external and clinically important relationships with the kidneys, ureters, cecum, appendix, colon, sigmoid colon, pancreas, lumbar lymph nodes, and nerves of the posterior abdominal wall. When one of those structures is affected by disease, the use of this muscle can cause pain. Likewise, infections in these organs can, by contiguity, affect the psoas muscle. Psoas abscess is a rare condition 1 and, therefore, not discussed frequently in primary care facilities, but one should keep it in mind to make the correct diagnosis.
Psoas abscess can be classified as primary or secondary, depending on the presence or absence of a baseline disorder. In 1985, the cases of psoas abscesses described in developing countries were of primary origin, while in the United States and Canada, almost 50% of the cases were of secondary 2. Studies suggest that the primary psoas abscess is more common in young patients, and 83% of the cases were described in patients younger than 30 years. On the other hand, about 40% of secondary psoas abscesses described affected individuals older than 40 years. Eighty-six percent of the patients with primary psoas abscesses were IV drug users 3, which is probably due to its rich vascular bed, making it susceptible to the hematogenous spread of infections.
The objective of this study was to report the case of a patient with pain in the right lower limb due to peripheral vascular insufficiency. The patient underwent epidural analgesia for the treatment of pain and developed a secondary psoas abscess.
A white, female patient, 65 years old, was admitted to the hospital with a 10-day history of pain, hyperemia, and bullae in the lower limbs. Past medical history was positive for chronic peripheral vascular disease, valvular cardiopathy, atrial fibrillation, and implantation of a biological mitral valve 11 years before admission. Medications included digoxin, pentoxyfillin, and furosemide in the habitual doses. Physical exam revealed the patient to be anxious, febrile, tachycardic, tachypneic, with edema and hyperemia of the lower limbs. She was diagnosed with cellulites in the lower limbs and treated with intravenous gatifloxacin (400 mg.day-1), tramadol (400 mg.day-1), and dypirone (4 g.day-1). The infection improved, but the patient continued to complain of severe, continuous pain in the right inferior limb, which increased with ambulation. The patient was referred to the pain clinic, and, due to the suspicion of neuropathic pain secondary to peripheral vascular insufficiency, it was proposed a treatment that consisted of gabapentin, fluoxetine, and a tunneled epidural catheter for the administration of 0.1% ropivacaine and 0.004% morphine. Twenty days after the procedure, close to the discontinuation of the epidural treatment, the patient presented with lumbar pain, headache, and high fever. Laboratory exams, cultures, and a CT scan of the pelvis were done, and the epidural administration of drugs was discontinued, followed by the removal of the catheter. Paracetamol (3,000 mg.day-10) and codeine (120 mg.day-1) were prescribed to treat the pain. A CT scan showed a psoas muscle abscess, and the patient was treated with the closed drainage of the abscess and ciprofloxacin (800 mg.day-1). Cultures were negative. The patient was discharged after a few days, without complaints, and instructed to follow-up at the outpatient clinic.
Several baseline conditions contribute for the formation of a secondary psoas muscle abscess. The most important are femoral artery catheterization, genitourinary diseases, gastrointestinal diseases, musculoskeletal disorders, and nerve block with the insertion of a catheter in the lumbar region. Here we present the case of a psoas muscle abscess secondary to the introduction of an epidural catheter for the treatment of pain difficult to control. Epidural abscess is the main infectious complication of regional anesthetic techniques, and potentially deleterious 4-8, which, although uncommon, can be associated with a psoas muscle abscess. Although this suggests the possibility of a coexisting epidural abscess, in the case presented here it was not confirmed by radiological exams. The absence of epidural infection is possible if the epidural catheter migrates out of the intervertebral foramen and in the presence of contamination of the anesthetic solution 9.
Four infectious routes are possible: 1) hematogenous to the psoas muscle; 2) catheter contamination; 3) contamination of the solution injected; and 4) inadequate skin asepsis before inserting the catheter. Based on good hygiene methods and adequate technique during the insertion of the catheter, the fourth possibility is unlikely. Hematogenous contamination, and contamination of the catheter and anesthetic solution are possible, since there are no established norms for the preparation of those medications in the pharmacy of the hospital where the patient was.
The symptoms of psoas abscess are not specific. The patient may present fever, lumbar pain, abdominal pain, and difficulty in walking. Since the innervation of the psoas muscle is provided by the roots from L2 to L4, pain secondary to inflammation of this muscle can irradiate anteriorly, to the hips and thighs. Other symptoms include nausea, malaise, and weight loss. However, these symptoms are common to several syndromes, hampering the diagnosis 10. In this case, the patient presented lumbar pain, high fever, and headache, which motivated the request for laboratory and radiological exams that demonstrated the presence of a psoas muscle abscess.
The treatment of a psoas muscle abscess includes antibiotics and drainage. The most common pathogens guide the choice of antibiotics, which should be adjusted according to the results of culture and sensitivity. Staphylococcus aureus is present in 80% of the cases of primary psoas muscle abscess. Other pathogens include Serratia marcescens, Pseudomonas aeruginosa, Haemophilus aphrophilus, and Proteus mirabilis. Secondary psoas muscle abscess is usually caused by enteric bacteria. Mycobacterium tuberculosis is an extremely rare cause of psoas muscle abscess in the United States. In areas where tuberculosis still is a common disease, it continues to be an important cause 11-14. In this case, even though cultures were negative, the patient was treated with ciprofloxacin (800 mg.day) and percutaneous drainage, with complete resolution of the infection.
Psoas muscle abscess is a rare infectious complication of epidural analgesia. The correct diagnosis is fundamental for a good evolution. The patient should be watched closely when an epidural catheter is used, even after its removal.
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Dra. Anita Perpétua Carvalho Rocha
Rua Pacífico Pereira, 457/404 Garcia
40100-170 Salvador, BA
Submitted em 05
de janeiro de 2006
Accepted para publicação em 27 de novembro de 2006
* Received from Hospital Universitário Professor Edgard Santos, da Universidade Federal da Bahia (UFBA), Salvador, BA